A call for help!
I’m asking for your help to help a new research idea in any way that you can. Maybe you might wish to collaborate by being a participant, a co-researcher or by passing on this information to somebody else. Please read on! There is a bit of reading to be done in this article but I will be delighted if you will ‘go the distance’ with me.
Background to my Tri-Factor research idea
I have had a hunch for quite a while emerging from my clinical psycho-therapeutic practice that there are many people who think they would benefit from working on their mental health but, for a variety of reasons, are unable to avail of the type of service they would like this. The typical reason might be financial and socio-economic, but other factors including time and availability of practitioners might also be relevant.
I decided to put this to the test late in 2018. I decided to offer a ‘stranger’ short-term men’s group based in Midleton, Co. Cork. A group like this is generally not available in that part of the world but many people said to me that there must be a great need for it. The common perception is that men might have difficulties in talking about their lives and a group might be a good way to get them to open up. They were right and a group of individuals and I managed to commence and maintain a successful group starting in January 2019. I made some adjustment for those who struggle with money, including a suitable payment term for those where paying the fee in one payment was a problem. I’m hoping to start additional groups based on this model after Easter, another one in Midelton, another in Bandon in West Cork, and possibly one in Tallaght, Co. Dublin in due course.
Getting off the couch and engaging with my health
I then started to think about my own health. have struggled with my weight over the last few years, due to an imbalanced eating and drinking pattern accompanied by an inadequate exercise regime. I had been a reasonable athlete all through my life but I eased off having finished my work as a referee in 2011. And the weight came upon me, nothing to do with the fact that I hadn’t changed my lifestyle at all!
I bit the bullet last autumn and started a ‘Couch to 5k’ running programme. I confess to being embarrassed at having to start again from square one. I then combined this with an improved nutritional intake. And the result was a better me, and I have no doubt at all that it contributed to a better state of mind (even though I have been in psychotherapy over the last number of years).
Combined Tri-Factor (Talk, Nutrition and Fitness) Therapy?
I then reflected that I have had clients in my clinic who presented with a ‘minor psychiatric disorder’ (e.g. somatic symptom, social dysfunction, anxiety, depression) but, as the treatment proceeded, also presented with issues in relation to digestion and nutrition. One of these clients, who was experiencing panic attacks, made his own assessment that the nutrition issue was related in some way to the symptom of anxiety.
Additionally, clients have sometimes asked me how long a psychoanalytic treatment would take to dissipate or eliminate a symptom they had initially presented with. Whilst never being definitive with clients on this subject, I have reviewed my own case files to check how long it typically takes for clients to tell me that a presenting symptom has been reduced
I am aware anecdotally of the work in the APC Microbiome brain-gut research from UCC, as well as research in the area of fitness, both interventions having a link with positive mental health outcomes.
My question was how could I help patients presenting with mental health issues but also nutrition/digestion issues at the same time? And how could I develop a time limited therapy, bearing in mind that my own psychoanalytic practice can never offer this…My idea was to think about offering my clients an eight-week time-limited psychotherapy programme to clients, together with a simultaneous nutrition/fitness intervention?
I reviewed the literature and have not been able to find any research or study involving an integrative approach of this nature designed to deal with minor psychiatric disorders, What I did find, however, was a recent study on the benefits of time-limited, brief interpersonal psychotherapy (IPT). IPT is a brief, attachment-focused psychotherapy that centres on resolving interpersonal problems and symptomatic recovery. It is an empirically supported treatment (EST) that follows a highly structured and time-limited approach and is intended to be completed within 12–16.The study of Swartz et al (2014)[i] (see https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4603530/) involved a modified version (IPT-B) of the standard form of interpersonal psychotherapy (IPT). They demonstrated that their modified approach delivered positive therapeutic effects, accompanied by decreased resource utilisation within an eight-week period.
I them found another US-based study by Wadden et al (2012)[ii] incorporating a comprehensive program of lifestyle modification, also referred to as behavioral weight control, which includs the three factors of diet, exercise, and behavior therapy. Expert panels sponsored by both the World Health Organization and the National Institutes of Health have recommended that obese adults (ie, body mass index ≥30 kg/m2), as well as those who are overweight (body mass index of 25–29.9 kg/m2) and have comorbid conditions, lose 10% of their initial weight. They conclude that obese individuals can lose weight by following reducing diets that vary widely in macronutrient composition, whilst physical activity appears to be critical for long-term weight management. That study can be found on the following link:
I then found an additional related study in Finland. Mathisen et al (2017)[iii] have a clinical trial underway looking at the effect of physical exercise and dietary therapy compared with cognitive behavior therapy in treatment of bulimia nervosa and binge eating disorder (https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-017-1312-4). They point out that sufferers from bulimia nervosa (BN) and binge eating disorder (BED) underestimate the severity risk of their illness and, therefore, postpone seeking professional help for years. Moreover, less than one in five actually seek professional help and only 50% respond to current treatments, such as cognitive behavioral therapy (CBT). The impetus for the present trial is to explore a novel combination treatment approach adapted from physical exercise- and dietary therapy (PED-t) as an alternative to CBT.
I haven’t been able to find anything else in the literature on the combination of the tri-factors and I decided that I would engage in some initial research on the subject.
Tri-Factor Pilot Study
I have developed a Dublin and Cork based research programme called ‘Go the Distance’, with interventions in the area of (i) time-limited talk therapy (ii) nutrition and (iii) exercise. The purpose of the research is to assess the benefits associated with a programme that combines each of these individual components.
The programme starts with an initial meeting with me (acting as Clinical Director). I explain to the client the process involved in the programme and deal with any questions they may have. I act as the central point of contact for the client throughout the programme.
I then ask the participant to complete three pieces of information:
- A Client Intake form providing basic background information including relevant medical information ;
- The GHQ28, which is a clinical screening measure used to detect possible psychological disorder (e.g. somatic symptom, anxiety, depression etc)
- Informed Consent documentation.
Once this documentation is signed by the client and returned to me, the client then contacts a partner who will make an appointment for an initial Nutritional Consultation. The initial consultation will last up to one hour. The client is asked to complete a comprehensive health questionnaire prior to their appointment. This is reviewed by the nutritionist before the appointment to make the most of the consultation time. The nutritionist will take a number of ‘anthropometric measurements’ which are systematic measurements of the size, shape and composition of the human body.
All of the initial data is shared with the other members of the programme i.e. the talk therapist and the fitness coach. The client then contacts both of these team members to make initial appointments. The following will be the full schedule of appointments during the duration of the programme:
- Nutrition – Initial one-hour intake followed by four check-in sessions of thirty minutes duration;
- Talk Therapy – eight appointments of one hour
- Fitness – eight appointments of one hour.
- Intake and closing meeting with the Clinical Director – two meetings of 30 minutes each.
The client is provided with a Fitbit device which they wear during the course of the programme. I then seek the permission of the client to take the data from the device and provide the data to the other team members. (I have also considered the taking of ‘bloods’ in order to establish blood-glucose levels etc.).
I have arranged clinical supervision for the team members at the half way stage of the client’s programme (typcial5-6 weeks after intake). The session is facilitated by a consultant psychiatrist.
The programme finishes with a final session with the Clinical Director to complete the GHQ28 for a second time and to receive the client;s feedback on the Programme.
It is anticipated that the total programme will be completed within a 10-12 week period from the time of intake, allowing for holidays, postponements etc. I estimate that the programme will take approximately 20 hours of the client’s time working with the team, excluding travelling time to appointments.
Current status of Research
I have enrolled three people to date on to this programme, both of whom constitute ‘friends and family’. I am partnered in this work by a well-known nutrition service provider (Glenville Nutrition) and a fitness provider operating in both Cork and Dublin (SmartTraining). I’m also partnered by local providers in the Midleton area.
I believe that this integrative programme will deliver positive health benefits to participants. I’m considering sourcing a supervisor for the work. My idea is to look to enroll further participants including some sourced via the GP network. I’m seeking a clinical supervisor for the work and am also considering recruiting a GP as Lead Investigator in order to add credibility to the work.
I understand that a programme of this nature is provided within the HSE, but I’m not aware of it being provided within the private domain as things stand. I’m funding this work at the moment, but am hoping that participants enrolled via the GP network might be willing to contribute to the (not inconsiderable) costs of the work.
Why am I telling you about this? Now?
I confess that I am a bit of an intellectual, which probably means that I am a bit of an outsider as well. It means that I am constantly considering new ways of approaching old problems, and also that I do not necessarily the prevailing disccourse and the status quo, and my idea in relation to the Tri-Factor approach is consistent with my way of going about things.
But there is also a social justice aspect to my idea. I believe that an offering like I am suggesting should be available to anybody who would benefit from it, and there must be a way to make it happen.
How might you help?
How might you help? It’s possible that you know of somebody who might be interested in enrolling in the programme? Or you might know of a professional who might be willing to collaborate with me in some way with the work? Or you might think that this is a crazy idea and that I need to make a serious modification to make it fly – if so, I shall be glad to take your feedback.
Please engage with me and let me know what you think. Please be part of this action research.
[i] Swartz, H.A., Grote, N.K. and Graham, P., (2014). Brief interpersonal psychotherapy (IPT-B): overview and review of evidence. American journal of psychotherapy, 68(4), pp.443-462
[ii] Wadden, T.A., Webb, V.L., Moran, C.H. and Bailer, B.A., (2012). Lifestyle modification for obesity: new developments in diet, physical activity, and behavior therapy. Circulation, 125(9), pp.1157-1170.
[iii] Mathisen, T.F., Rosenvinge, J.H., Pettersen, G., Friborg, O., Vrabel, K., Bratland-Sanda, S., Svendsen, M., Stensrud, T., Bakland, M., Wynn, R. and Sundgot-Borgen, J., (2017). The PED-t trial protocol: The effect of physical exercise–and dietary therapy compared with cognitive behavior therapy in treatment of bulimia nervosa and binge eating disorder. BMC psychiatry, 17(1), p.180.